Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 26
CPT code lookup
Each row is one code from the public prior authorization list. The description is the procedure or service name on that source row. This is not a coverage decision.
Prior authorization codes
| Code | Description | Source |
|---|---|---|
| 37228 | Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal angioplasty | New Hampshire Precertification List, Pg 113 Original policy |
| 37229 | Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with atherectomy, includes angioplasty within the same vessel, when performed | New Hampshire Precertification List, Pg 113 Original policy |
| 37230 | Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed | New Hampshire Precertification List, Pg 113 Original policy |
| 37231 | Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed | New Hampshire Precertification List, Pg 113 Original policy |
| 37232 | Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with transluminal angioplasty (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 113 Original policy |
| 37233 | Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with atherectomy, includes angioplasty within the same vessel, when performed (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 113 Original policy |
| 37234 | Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 114 Original policy |
| 37235 | Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 114 Original policy |
| 37241 | Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; venous, other than hemorrhage (eg, congenital or acquired venous malformations, venous and capillary hemangiomas, varices, varicoceles) | New Hampshire Precertification List, Pg 114 Original policy |
| 37242 | Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; arterial, other than hemorrhage or tumor (eg, congenital or acquired arterial malformations, arteriovenous malformations, arteriovenous fistulas, aneurysms, pseudoaneurysms) | New Hampshire Precertification List, Pg 114 Original policy |
| 37243 | Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for tumors, organ ischemia, or infarction | New Hampshire Precertification List, Pg 114 Original policy |
| 38204 | Management of recipient hematopoietic progenitor cell donor search and cell acquisition | New Hampshire Precertification List, Pg 114 Original policy |
| 38205 | Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; allogeneic | New Hampshire Precertification List, Pg 114 Original policy |
| 38206 | Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; autologous | New Hampshire Precertification List, Pg 114 Original policy |
| 38207 | Transplant preparation of hematopoietic progenitor cells; cryopreservation and storage | New Hampshire Precertification List, Pg 114 Original policy |
| 38208 | Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor | New Hampshire Precertification List, Pg 115 Original policy |
| 38209 | Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, with washing, per donor | New Hampshire Precertification List, Pg 115 Original policy |
| 38210 | Transplant preparation of hematopoietic progenitor cells; specific cell depletion within harvest, T-cell depletion | New Hampshire Precertification List, Pg 115 Original policy |
| 38211 | Transplant preparation of hematopoietic progenitor cells; tumor cell depletion | New Hampshire Precertification List, Pg 115 Original policy |
| 38212 | Transplant preparation of hematopoietic progenitor cells; red blood cell removal | New Hampshire Precertification List, Pg 115 Original policy |
| 38213 | Transplant preparation of hematopoietic progenitor cells; platelet depletion | New Hampshire Precertification List, Pg 115 Original policy |
| 38214 | Transplant preparation of hematopoietic progenitor cells; plasma (volume) depletion | New Hampshire Precertification List, Pg 115 Original policy |
| 38215 | Transplant preparation of hematopoietic progenitor cells; cell concentration in plasma, mononuclear, or buffy coat layer | New Hampshire Precertification List, Pg 115 Original policy |
| 38230 | Bone marrow harvesting for transplantation; allogeneic | New Hampshire Precertification List, Pg 115 Original policy |
| 38232 | Bone marrow harvesting for transplantation; autologous | New Hampshire Precertification List, Pg 115 Original policy |
| 38240 | Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor | New Hampshire Precertification List, Pg 115 Original policy |
| 38241 | Hematopoietic progenitor cell (HPC); autologous transplantation | New Hampshire Precertification List, Pg 115 Original policy |
| 38243 | Hematopoietic progenitor cell (HPC); HPC boost | New Hampshire Precertification List, Pg 115 Original policy |
| 41019 | Placement of needles, catheters, or other device(s) into the head and/or neck region (percutaneous, transoral, or transnasal) for subsequent interstitial radioelement application | New Hampshire Precertification List, Pg 115 Original policy |
| 41512 | Tongue base suspension, permanent suture technique | New Hampshire Precertification List, Pg 115 Original policy |
| 41530 | Submucosal ablation of the tongue base, radiofrequency, 1 or more sites, per session | New Hampshire Precertification List, Pg 115 Original policy |
| 42145 | Palatopharyngoplasty (eg, uvulopalatopharyngoplasty, uvulopharyngoplasty) | New Hampshire Precertification List, Pg 115 Original policy |
| 43192 | Esophagoscopy, rigid, transoral; with directed submucosal injection(s), any substance | New Hampshire Precertification List, Pg 116 Original policy |
| 43201 | Esophagoscopy, flexible, transoral; with directed submucosal injection(s), any substance | New Hampshire Precertification List, Pg 116 Original policy |
| 43210 | Esophagogastroduodenoscopy, flexible, transoral; with esophagogastric fundoplasty, partial or complete, includes duodenoscopy when performed | New Hampshire Precertification List, Pg 116 Original policy |
| 43229 | Esophagoscopy, flexible, transoral; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed) | New Hampshire Precertification List, Pg 116 Original policy |
| 43233 | Esophagogastroduodenoscopy, flexible, transoral; with dilation of esophagus with balloon (30 mm diameter or larger) (includes fluoroscopic guidance, when performed) | New Hampshire Precertification List, Pg 116 Original policy |
| 43235 | Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) | New Hampshire Precertification List, Pg 116 Original policy |
| 43236 | Esophagogastroduodenoscopy, flexible, transoral; with directed submucosal injection(s), any substance | New Hampshire Precertification List, Pg 116 Original policy |
| 43239 | Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple | New Hampshire Precertification List, Pg 116 Original policy |
| 43241 | Esophagogastroduodenoscopy, flexible, transoral; with insertion of intraluminal tube or catheter | New Hampshire Precertification List, Pg 116 Original policy |
| 43243 | Esophagogastroduodenoscopy, flexible, transoral; with injection sclerosis of esophageal/gastric varices | New Hampshire Precertification List, Pg 116 Original policy |
| 43244 | Esophagogastroduodenoscopy, flexible, transoral; with band ligation of esophageal/gastric varices | New Hampshire Precertification List, Pg 116 Original policy |
| 43245 | Esophagogastroduodenoscopy, flexible, transoral; with dilation of gastric/duodenal stricture(s) (eg, balloon, bougie) | New Hampshire Precertification List, Pg 116 Original policy |
| 43246 | Esophagogastroduodenoscopy, flexible, transoral; with directed placement of percutaneous gastrostomy tube | New Hampshire Precertification List, Pg 116 Original policy |
| 43247 | Esophagogastroduodenoscopy, flexible, transoral; with removal of foreign body(s) | New Hampshire Precertification List, Pg 116 Original policy |
| 43248 | Esophagogastroduodenoscopy, flexible, transoral; with insertion of guide wire followed by passage of dilator(s) through esophagus over guide wire | New Hampshire Precertification List, Pg 117 Original policy |
| 43249 | Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic balloon dilation of esophagus (less than 30 mm diameter) | New Hampshire Precertification List, Pg 117 Original policy |
| 43250 | Esophagogastroduodenoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps | New Hampshire Precertification List, Pg 117 Original policy |
| 43251 | Esophagogastroduodenoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique | New Hampshire Precertification List, Pg 117 Original policy |